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PREAMBLE OF THE CLINICAL PRACTICE GUIDELINES FOR ELDERLY
|Year : 2018
: 60 | Issue : 7 | Page
|The Geropsychiatric Interview- Assessment and Diagnosis
Mathew Varghese, Ajit Bhalchandra Dahale
Geriatric Psychiatry Services, NIMHANS, Bangalore, Professor of Psychiatry, National Institute of Mental Health & Neuro Sciences (NIMHANS), BANGALORE-560029, INDIA, India
Click here for correspondence address and
|Date of Web Publication||6-Feb-2018|
|How to cite this article:|
Varghese M, Dahale AB. The Geropsychiatric Interview- Assessment and Diagnosis. Indian J Psychiatry 2018;60, Suppl S3:301-11
| Introduction|| |
The population of elderly persons is growing with extraordinary rapidity. In the 2011 census of India the elderly population comprised over 8 % of the total population, making the estimated numbers of people above 60 years age to over 100 million. Although the majority enjoys good health, many older people suffer from multiple illnesses and significant disability. They tend to exhibit great medical complexity and vulnerability, have illnesses with atypical and obscure presentations, suffer major cognitive, affective, and functional problems, are especially vulnerable to iatrogenic health problems, are often socially isolated and poor and are at high risk for premature or inappropriate institutionalization. Almost 45% of elderly suffer from some chronic illness and many have two to three physical illnesses together with a mental disorder. The prevalence of mental disorders in the elderly ranges from 20-30% of which the commonest are depression (10%) and dementia (3%). Hence it is very important to recognise the magnitude of the problem as India would have the second largest population of elders in the world with a mental disorder. This fact would necessitate that we anticipate and plan for geriatric care both in the health system and in the families and community.
| The Psychiatric Interview of the Elderly Patient|| |
The bedrock of the diagnostic workup of an elderly patient with a psychiatric disorder is the psychiatric interview. In this chapter, we would detail the core components of the psychiatric history taking, the mental status examination and other bedside assessments. We would also assess other domains important for the comprehensive management of the patient like the medical, social, financial, environmental areas. A brief note would also be given on the laboratory and other investigations required to confirm a diagnosis. We will also list out some structured interview schedules and rating scales that are of value in the geropsychiatric assessment.
| The Psychiatric Evaluation:|| |
The clinician should first interview the patient together with the family members to understand the presenting problem for which the consultation is made. Later it may be necessary to interview the patient and family members separately for information that is pertinent from the respective persons. For example, it is better to interview the patient separately when doing the neuropsychological testing or when patient appears to be inhibited to discuss his/her symptoms and to talk to the family separately while enquiring about caregiver burden and distress. If the patient has difficulty providing a reliable and adequate history, the clinician should elicit the symptoms or problems that the patient perceives as being most disabling and then fill the gaps with data from the family members. Interview techniques for patients with sensory [e.g hearing loss] or cognitive impairment should be appropriately modified to reduce inducing anxiety or irritability, for e.g. by talking slowly and by explaining the nature and rationale of the assessments.
The areas to focus in the history taking interview are given below:
- Presenting complaints and history of the current illness
- Past psychiatric and medical history
- Medication history
- Family history and assessment
- Personal history (including habits, nutrition, biological functions and life style)
- Premorbid personality
- Mental Status Examination
1. The History of current illness
The review of symptoms is most valuable when considered in the context of symptom presentation, including onset, duration, severity and fluctuation, precipitating factors/life events, prior efforts at addressing the symptoms and their success, diurnal or seasonal variation, whether symptoms cluster together, and whether they are ego-syntonic or ego-dystonic. Open ended questioning should be attempted initially followed by structured questioning. Defining a 1-month or 6-month window enables the patient to review symptoms and events temporally—an approach not usually taken by distressed elders, who tend to concentrate on immediate sufferings.
Critical to the assessment of the current illness is an assessment of function and change in function. The two parameters that are most important are social functioning and activities of daily living (ADLs). Questions should be asked about the social interaction of the older adult, such as the frequency of his or her visits outside the home, telephone calls, and visits from family and friends. The clinician must ask about the patient's ability to get around (e.g., walk inside and outside the house), to perform certain physical activities independently (e.g., bathe, dress, shave, brush teeth, and select clothes), and to do instrumental activities (e.g., cook, maintain a bank account, shop, and drive). It is also important to assess how often the elder actually engages in these activities.
The clinician must take care to avoid accepting the patient's explanation for a given problem or set of problems, yet should acknowledge their perspective for developing better rapport and understanding their explanatory model. Statements such as “Most people slow down when they get to be my age” can lull the clinician into complacency about what may be a treatable psychiatric disorder. Also, the advent of new and disturbing symptoms in an older adult between office visits can exhaust the clinician's patience, thereby derailing pursuit of the problem. Distress over changes in functioning, such as sexual functioning, may overwhelm the older adult patient and, especially if the clinician is perceived as unconcerned, may precipitate self-medication or even a suicide attempt. The clinician should be watchful regarding the discrepancies between report by patient and family member/informant about the symptoms and should assess for the motivations behind the same. Sometimes multiple family members can also give conflicting accounts of patient's clinical picture, this should alert the clinician to assess for the underlying motivations or family issues. This would help the clinician plan the interventions for patient and family in a better way.
2. Past Medical & Psychiatric History:
A past history of psychiatric disorder or details of past episodes of illness should be documented together with treatments given (medicines, psychological therapy, ECT etc.), response to the treatments and side-effects if any. Also, past or concurrent medical illnesses are important in the causation, co-morbid interaction and for current planning of the treatments. In patients with cognitive decline it is prudent to check for occurrence of depressive symptoms prior to the onset of cognitive symptoms. Getting reliable and adequate information about the past history may be a challenge due to poor memory of the patient and inadequate information from the accompanying family members. Nevertheless, it is useful to explain to the family why this information is important and to get past medical records that may be available at home. Wherever it is possible to liaise, it would be very useful to discuss with clinicians involved in patient's concurrent medical conditions for more comprehensive care and avoiding confusion in management by the different clinicians.
3. Medication History:
All the medicines taken by the patient should be reviewed. Though some of these medicines would have been prescribed by another physician, many elders take over-the-counter (OTC) medicines, alternative medicine treatments or other medicines orally advised by some friend or family member (usually for pain, digestion, bowel movements, sleep or anxiety). A review must be made comparing the prescription and the actual dosage that the elder is taking. Very commonly there may be a discrepancy due to a problem of forgetfulness or due to confusion because of too many pills being prescribed. In addition to OTC or prescribed medicines same elders may abuse alcohol, tobacco or other drugs to counter their mental or physical symptoms. Hence it is prudent to enquire about intake of these substances which may cause harm or dependence.
4. Family History & Assessment:
It is useful to draw a 3-generation genogram of the family of the patient. The genogram helps in many ways. In addition to eliciting a history of similar or other mental illnesses in the family we should also get details of the family's socioeconomic status, social supports, knowledge and attitudes of the family members towards patient's condition, any family conflict or possibility of abuse of patient or legal issues and details of possible caregivers of the patient. In addition to a history of any mental disorder or suicide, enquiry must also be made about significant chronic medical illnesses like hypertension, diabetes mellitus, stroke and other vascular risk factors. Interviewing multiple family members, and preferably more than one generation will help in improving accuracy.
It is very important for the geriatric psychiatrist to engage with the family and to plan family interventions as most treatment plans would need the cooperation and involvement of family members. In addition to the family support that is required to manage the patient, the family is important for discussion of economic, social and legal matters. The psychiatrist also needs to work with the family to provide support and to relieve caregiver stress that is commonly faced by caregivers as this has implications for patient's health and care as well.
5. Personal History:
A developmental life cycle perspective could be used to get relevant details of the person from the time of birth. The patient's performance in school and college and the occupational history about his past jobs and employment history would highlight his functional ability in the past. The age and circumstances of retirement will inform of his attitude to work and retirement. Part or full-time jobs held after retirement contribute to income and function. Information about patient's cultural, spiritual life and values would be helpful in understanding the patient better and planning the management. The nutrition history should give the type, quantity, and frequency of food eaten, including the number of hot meals per week. Any special diets (eg. low salt, low carbohydrate) or self-prescribed fad diets are noted. The intake of alcohol, dietary fibre, and prescribed or over-the-counter vitamins is recorded. The amount of money the patient must spend on food and the accessibility of food stores are important issues. Lack of suitable kitchen facilities may prevent a patient from preparing meals. The patient's ability to eat (chewing, swallowing) is assessed. It may be impaired by xerostomia (dry mouth), which is common in the elderly. Decreased taste or smell may reduce the pleasure of eating, so the patient may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients who are worried about urinary incontinence may reduce their fluid intake, which may also lead to poor food intake.
| The Mental Status Examination:|| |
The mental status examination of the elderly psychiatric patient is crucial to the psychiatric diagnosis and clues to many of these signs would be evident from a thorough history-taking interview. The MSE may be evaluated on the standard format used which covers the following areas:
- General appearance & behavior (including psychomotor activity)
- Language and thought disorders
- Cognitive functions- focusing on orientation, attention, concentration, memory, intelligence
- Judgement and insight
1. The general appearance of the patient, his grooming and dressing would give an indication of how the person is able to take care of themselves. In patients who are depressed, demented or have psychotic symptoms the appearance of the patient may give clues to the diagnosis. The facial expression of the patient and the rapport that is possible with the examiner would give an indication of whether the patient is going through a psychotic or less serious illness. The associated bodily movements and posture of the patient would give further clues to the underlying psychopathology. The psychomotor activity (whether increased or retarded), general agitation and fidgetiness, aimless pacing or distractibility of the patient would give valuable clues as to whether there is depression, mania, psychoses, delirium, dementia or generalized anxiety.
2. Language and thought disturbances: Disturbances in thought content and stream are the most common disturbances in persons with depression, psychoses and sometimes with dementia. It is quite common for elder depressed patients to have negative cognitions like worthlessness, pessimism, hypochondriacal preoccupation or nihilism. Patients with psychoses or dementia may have delusions of persecution, somatic delusions or of family members stealing their personal belongings. Patients who have anxiety and depression are likely to have worry or preoccupation and tend to be repetitive in their thinking. Sometimes the repetitive speech may be as a result of perseveration, confabulation or other speech disorders seen in organic disorders. The speech may become irrelevant or incoherent with seeming disorders in associations or form. Difficulty with respect to language may be the initial feature in patients with dementia. Also, patients with stroke can have aphasia or slurring of speech.
It is very important to not miss asking for and assessing suicidal ideas. Though thoughts of death are common in late life, elders do not readily express ideas of suicide. Hence it is prudent to gently and specifically ask about ideas of life not worth living, a wish to die or for specific plans or even attempts. The threat of suicide is very high in the elder population and many psychiatrists have suddenly lost patients to suicide when they least expected it. As the risk is very high it is necessary to assess if the implements [methods] required for DSH are readily available to the patient.
3. Mood and Affect can be assessed by observing the patient during the interview, getting their subjective report of emotions that they experience and by assessing the stream and content of their thoughts. It must be remembered that the older adults' repertoire of emotions may be constricted and they may not exhibit the degree of sadness as younger persons would. On the contrary, they may exhibit apathy instead of anxiety or sadness. Labile affect can be noted in patients suffering with dementia.
4. Perceptual disorders in the elderly quite commonly can occur in all the five realms. Though auditory and visual hallucinations or illusions are very common, it is also common to see tactile, olfactory and gustatory sensations especially when there is an organic condition or psychoses. Patients with depression may also experience bad taste and odors like that of putrefaction.
5. Cognitive functions and Memory are most accurately assessed by formal psychological testing. However, the psychiatric interview of the older adult must include a reasonable bedside assessment of cognitive functions. Cognitive functions should be assessed in the sequence of first testing for orientation, moving on to attention and concentration and then memory and other higher functions like intelligence, abstraction and judgement. This sequence should be followed as testing of memory and other higher functions would require an intact attention, concentration and orientation. Very commonly a disorder of attention, concentration, orientation, or lack of interest due to a psychiatric illness (depression or psychoses) may be mistaken for dementia if not tested properly.
Attention and concentration is tested by the digit span test (digit forward and backward). In illiterate elders, we could use days of week forward and backward or the 20-1 test. Serial subtraction (100-7 or 40-3) is a test for concentration and immediate memory and intelligence. Orientation can be very simply checked by asking the patient's awareness to the time (time of day, day, date, month, etc), place (where, town, address etc) and person (self, relatives, bystanders, etc).
Memory is tested in the domains of immediate, recent and remote memory. Testing of memory is based on three essential processes of registration, retention and recall. Memory is tested by asking the subject to learn and memorize 3 or 5 objects and asking them to recall after a few minutes after doing other tests. Asking the person to recall an address with five different components is also an accepted test for recent memory. Remote memory can be tested by asking the subject to recall important local events in the past. This may take the form of information required for general information like the name of a political leader, date of independence or time of festivals. It is not very accurate to ask for details of meals that were eaten or events in the past day though sequencing of events in the past few days may be an indication of temporal spatial dysfunction Memory which is autobiographical is lost last and so may be used to test subjects who are moderately demented.
Registration is usually not impaired except in patients with a moderate to severe dementia. However, retention can be impaired by both psychic distress and brain dysfunction. For example, lack of retention will be evident if unimportant data like asking the patient to remember 3 objects for 5 minutes will frequently score a deficit if the patient has little motivation to do the task.
6. Judgement, abstraction and Insight:
Abstract thinking is tested by asking the subject to give the meaning and usage context of a common proverb. Alternately for illiterate elders we could use the similarities and differences test. Judgement and comprehension may be tested by asking the patient to say what he would do in certain situations (like the letter test, the fire in house test, or what to do when it rains).
Insight is tested by asking the person why he has come for consultation or whether he thinks he has an illness and the explanation of the illness. Patients with depression, anxiety or other milder forms of illness or mild cognitive impairment would have insight while subjects with dementia, florid psychosis or delirium would have absent insight.
Qualities of a geriatric psychiatrist & tips for effective communication:
Most elders are just anxious and tired when they come to a clinic and may have visual or hearing impairment that may cause confusion or poor performance in a test situation. Older adults require a lot of patience and compassion from the examiner and the examiner must address the elder in a respectful and concerned manner. It is important to speak slowly and clearly and repeat instructions (as some may have hearing or other impairments). In addition to verbal communication, non-verbal communication like being close to the patient, touch or helping the elder about in the clinic, would encourage cooperation of the elder for the detailed and tedious examination that is involved.
The geriatric psychiatrist must have a sense of humour, patience, a willingness to listen and explore possibilities and not jump to conclusions and like older people. Working with families is a key part of geriatric work. The person must also believe that geriatric patients with psychiatric issues do in fact get better and can lead a more fulfilling and enjoyable life. An interest in psychiatry, medicine and neurology is helpful and the person must have an understanding of the many complex biopsychosocial factors influencing psychiatric problems in an older person.
| The Comprehensive Geriatric Assessment|| |
As the elderly patient has multiple health problems that may exist together, it is necessary to thoroughly evaluate these problems that would have a bearing on comprehensive management. Accordingly, in addition to the psychiatric evaluation, many geriatricians recommend a Comprehensive Geriatric Evaluation. This is a process of multidisciplinary evaluation in which the multiple problems of older persons are evaluated, and the resources and strengths of the person are catalogued, the need for services assessed, and a coordinated care plan is developed to focus interventions on the person's problems.
The goals of comprehensive geropsychiatric assessment are:
- To improve diagnostic accuracy,
- To guide the selection of interventions to restore or preserve health,
- To recommend an optimal environment for care,
- To predict outcomes, and
- To monitor clinical change over time
The setting: Structured Comprehensive geriatric assessment may be done in many institutional settings, including acute care, psychiatric, or rehabilitation hospitals and nursing homes, and in ambulatory settings, including outpatient or freestanding clinics, the offices of psychiatrists and primary care physicians, or in the patient's home. It has often been applied to elderly persons at critical transition points in their lives, including actual or threatened decline in health and functional status, impending change in living environment, bereavement, or other unusual stress
Process: Comprehensive geropsychiatric assessment is initiated by a referral from one of many sources. In addition to the patient the process often includes family members and other important persons in the individual's environment. It is conducted by a core team that consists at a minimum, of a psychiatrist, nurse, and social worker, each with special expertise in caring for older people. The specific activities and contributions of each team member may vary considerably, and flexibility in roles may facilitate the assessment process.
The assessment begins with a case-finding approach that utilizes screening instruments and techniques. Based on these initial findings, a more detailed assessment is frequently undertaken. This in-depth assessment often requires the participation of many other professions. These may include audiology, clinical psychology, dentistry, nutrition, occupational therapy, optometry, pharmacy, physical therapy, speech pathology, and the clergy. Support from other medical disciplines, such as neurology, ophthalmology, orthopaedics, physiotherapy, surgery, and urology, is commonly needed. Self-rating scales completed by the patient or caregivers may provide some aspects of geropsychiatric assessment. Such information may lead to different insights than those obtained through external assessment performed by one member of the health care team.
Comprehensive Geriatric Assessment (Reuben,2003) comprises of the following components:
- Physical health
- Mental health
- Functional Status
- Social and Economic Status
- Environmental characteristics
1. Physical Health: A careful history is obtained from the patient and others with significant knowledge of the patient. Special attention is directed to the use of prescription and non-prescription medications and clues to the presence of malnutrition, falling, incontinence, and immobility. Data is gathered on smoking, exercise, alcohol use, immunization status and sexual function. Also important is information regarding the patient's personal strengths, values, perceived quality of life, acceptability of interventions, and expected outcomes from his or her health care.
The geriatric physical examination is performed with emphasis on identification of specific diseases or conditions for which curative, restorative, palliative, or preventive treatment may be available. Special attention is directed toward visual or hearing impairment, nutritional status, and conditions that may contribute to falling or difficulty in ambulation. Laboratory tests and other diagnostic studies are obtained as indicated.
The geriatric exam starts as soon as the patient is first seen (observations are made about the patient's appearance, speech, ability to move around, etc.) and continues after the formal exam is completed (i.e. does the patient have problems with dressing himself/herself, finding the way back to the car). Elderly patients may require additional time to undress and transfer to the examining table for the physical examination; they should not be rushed. The examining table is adjusted to a height that the patient can easily access; a footstool facilitates mounting. The patient must not be left alone on the table. Portions of the examination may be more comfortable if the patient sits in a chair. The patient may want a relative or aide in the room during the examination. Preliminary assessment of the patient's functioning can be made by observing personal hygiene. The patient's general appearance is described (eg. comfortable, restless, malnourished, inattentive, pale, dyspnoeic, cyanotic). If the patient is examined at bedside, use of a water mattress, a sheepskin, bedside rails (partial or full), restraints, a urinary catheter, or an adult diaper is noted. During measurement of height and weight, patients with balance problems may need to grasp grab bars placed near or on the scale. When the temperature is recorded, hypothermia can be missed if the thermometer does not measure low temperatures. The absence of fever does not exclude infection. The pulse and blood pressure (BP) are checked in both arms. The pulse is taken for 60 seconds and any irregularity noted. Because many factors can alter BP, several measurements are taken under resting conditions. As per the complaints of the patient examinations of other systems like respiratory, GIT, Skin, Eyes, Ears, Nose, Oropharyngeal, Neck/Thyroid, Lymphatic, Breasts, Heart, Peripheral Vascular, Abdomen, Musculoskeletal & Pelvic/Rectal may be carried out.
The neurological examination for an elderly patient, similar to that for any adult, assesses cranial nerves, motor function and sensory function. However, non-neurological disorders that are common among the elderly may complicate the neurological examination. For example, diminished sight and hearing may impede the assessment of cranial nerves, and peri arthritis of the shoulder due to hemiplegia may interfere with the assessment of motor function.
Signs detected during the examination must be considered in light of the patient's age, history, and other findings. Symmetric findings unaccompanied by functional loss, other neurological signs, and complaints may be a result of aging. The physician must decide whether these findings justify a detailed evaluation for a neurological lesion. Patients should be re-evaluated periodically for functional changes, asymmetry, or new complaints. Normal age-related changes seen on neuro exam are decreased lower extremity vibratory sensation, diminished knee jerk, diminished or absent ankle jerk. Look for cortical release signs such as grasp, palmomental, glabellar, and snout reflexes. Focused on looking for neurological deficits that may be a sign of neurological disease (CVA, Parkinson's, etc). Difficulty may be encountered in sensory exam if patient has altered mental status or aphasia.
2. Mental Health: Cognitive, behavioural, and emotional status is evaluated. Detection of dementia, delirium, and depression is particularly important. A range of assessment instruments is available for this purpose. For some patients a detailed psychiatric interview, a neurobehavioral consultation or comprehensive neuropsychological testing is indicated. Details of the mental status examination have already been discussed above.
3. Social and Economic Status: Evaluating the social support network includes identifying present and potential caregivers and assessing their competence, willingness to provide care and acceptability to the older person. This information may be obtained by questionnaires, structured interviews, or other methods. The degree of caregiver stress and the caregiver's support network also are considered. Areas of special importance to the individual, such as cultural, ethnic, and spiritual values, are noted. The individual's own assessment of the quality of life is recorded. The clinician evaluates the economic resources of the elderly person, which often determine access to medical and personal care and influence options for living arrangements
4. Functional Status: There are several components to a comprehensive assessment of an older person's ability to function. Physical functioning is usually measured by the ability to accomplish basic activities of daily living (ADL) including eating, bathing, toileting and dressing. Other components of functional well-being are behavioural and social activities that require a higher level of cognition and judgment than physical activities. These instrumental activities of daily living (IADL) include preparation of meals, shopping, light housework, financial management, medication management, use of transportation and use of the telephone. Functional status (ADL and IADL) is probably most accurately evaluated by direct observation of the patient by family or health professionals in the home or a simulated homelike environment. However, surprisingly accurate information is also obtained by standardized questionnaire or self-report.
5. Environmental Characteristics: Evaluating the patient's physical environment is essential. Home visits and questionnaires are used to determine the safety, physical barriers, and layout of the home as well as access to services, such as shopping, pharmacy, transportation, and recreation facilities
Home Visit Assessment: The Home Visit Assessment is an essential part of the comprehensive geriatric assessment most often done by social workers or public health nurses. This assessment is important to understand the impact of the patient's environment on his problems, particularly problems with risk of fall and functional disability. The home visit adds to the functional assessment via direct observation of a patient carrying out activities of daily living.
Assessing Competence: The level of Competence may be required to be assessed in light of all the above to check patients who have a cognitive dysfunction or are too seriously ill with a psychotic illness that makes it difficult for them to consent for treatment or for legal purposes. Though Competency is a Legal term it is assessed for a task within the specific framework as the person may vary in giving consent for different tasks. The points that are to be used for assessment are as follows:
- Give consent for medical treatment
- Give power of attorney, draw and change a will
- Consent by advance directives for research and withdrawal of life support systems
Outcomes: Research has shown that through Comprehensive Geriatric Assessment there was improvement in diagnostic accuracy. The assessment also prolonged survival, reduced annual medical care costs, reduced use of acute hospitalisation, reduced nursing home use, increased use of health/social services in the home, reduced medication use, improved placement and improved cognition/functional status.
BASIC LABORATORY INVESTIGATIONS AND OTHER STUDIES:
These laboratory investigations and other studies are ordered after the geriatric history and physical examination is completed and are used to detect diseases that are easily missed in the history and physical such as anaemia, renal impairment, hypothyroidism, vitamin B12 and vitamin D deficiency and especially reversible aetiologies of cognitive impairment (dementia).
Standardised neuropsychological batteries are available in India to assess for the patient's overall intellectual and cognitive function normalized to the patient's age and baseline educational and sociocultural level. These tests are important because we can often miss dementia completely in patients subjected to the traditional medical interview, particularly those that are well educated, socially adept, and in denial of their cognitive problems. These tests should be ordered for any geriatric patients that the clinician suspects to have dementia even if the patient has a normal screening (MMSE) score. The information from these tests will then allow for proper characterization of the pattern of cognitive deficits that will provide clues to the specific type of dementia the patient is suffering from. Also, they would help in periodic evaluation to look for progress over time and the effect of medicines.
A standard neuropsychological battery available for India is the Cognitive Screening Battery (Ganguli et al, 1996) and the NIMHANS Neuropsychological Battery for the Elderly (NNB-E). The Addenbrooke Cognitive Evaluation (ACE-R) has also been standardised and translations are available for many India languages.
Neuroimaging in Geriatric Psychiatry.
Neuroimaging techniques provide an opportunity to study the structure and function of the brain in Elderly. Structural imaging like CT Scan and MRI scan are useful tools though information is limited
The CT scan is affordable and is good to detect large structural lesions like haemorrhage (SDH) or infarcts, bony abnormalities and calcified tumours, AV malformations, and SOLs like Abscess, Tumours, inflammation and atrophy. It is quick easy to perform, less costly and can be done in presence of pacemakers and ferromagnetic bodies. Its limitations are low resolution, poor visualization of the posterior structures and isodense lesions (like cysts) and white matter pathology.
The MRI Scan detects white matter abnormalities and has excellent contrast between grey matter, white matter, and CSF. It is the scan of choice as it can clearly delineate tumours, abscess, haemorrhage, inflammation, and vascular abnormalities like AV malformations. Only disadvantage is its cost, time, and contraindications for metallic implants like pacemakers and orthopaedic prosthesis. Advances in radiotracer chemistry and instrumentation have increasingly positioned neuroimaging methods as an interface between basic and clinical neuroscience research.
The in vivo visualization of neurotransmitter metabolism, transporters, and receptors with single photon emission computed tomography (SPECT) and positron-emission tomography (PET) has been made possible by advances in radiotracer development. At present many leading centres are offering FDG- PET scans which may be used to study the brain metabolism in patients who have depression, MCI or dementia. Relevant to geriatric neuropsychiatry is the development of radiotracers for the in vivo visualization of amyloid and tau deposition in dementia and other neurodegenerative disorders. The amyloid and tau CT/MRI PET scans are yet available only for research purposes.
| Rating Scales and Standardised Interviews:|| |
Rating scales primarily used in research studies are useful in clinical practice in assessment of the elderly to delineate specific problems, documenting change, teaching and communicating with colleagues and they can be useful in insurance and medico legal purposes. There is a plethora of scales that can be used but there is no single scale or instrument to measure all pathology. In India there is also the issue of using tests in the local language and hence the issue of translation and validation in various languages to maintain its reliability and validity at the same time ensure that the items pertain to our culture and clinically appropriate. Some of the widely used scales are listed below.
| Cognitive Dysfunction and Dementia Schedules:|| |
The Mini-Mental State Examination is a 30-item screening instrument that assesses orientation, registration, attention and calculation, recall, and language. It requires 5–10 minutes to administer. As per Western country norms scores between 20 to 23 indicate mild dementia, between 10 to 19 indicate moderate dementia and below 10 indicate severe dementia. However, the diagnosis should not be solely based on the score but comprehensive assessment. This instrument is perhaps the most frequently used standardized screening instrument in clinical practice. The MMSE has been adapted in India (as the Hindi Mental State Examination-HMSE) and is used widely in many Indian clinics and in research studies.
Clock drawing test
The clock drawing test takes only 2 minutes to administer and reflects frontal and temporoparietal functioning (Brodaty & Moore, 1997; Shulman et al, 1986). The main advantages are its simplicity of administration and the non-threatening nature of the task. The patient is asked to draw a clock face marking the hours and then draw the hands to indicate a particular time (e.g. 10 minutes past 11 o'clock). Standardized methods of scoring have been described with sensitivities of up to 86% and specificity of up to 96% compared with diagnosis using the MMSE. This test is particularly useful in the general practice setting but cannot be used with illiterate population.
Clinical Dementia Rating (CDR) scale is used as a global measure of dementia (Hughes et al, 1982; Berg, 1984) and is usually completed by a clinician in the setting of detailed knowledge of the individual patient. Much of the information will therefore already have been gathered, either as part of normal clinical practice or as part of a research study. If a specific interview is carried out, about 40 minutes is needed to gather the relevant information. The full CDR interview is available in many Indian languages. The CDR has become one of the main methods by which the degree of dementia is quantified into stages. Six domains are assessed: memory; orientation; judgment and problem solving; community affairs; home and hobbies; and personal care. Ratings are 0 for healthy people, 0.5 for questionable dementia (or MCI) and 1,2 and 3 for mild, moderate and severe dementia as defined in the CDR scale.
| Behavioural and Psychological Symptoms|| |
The Neuropsychiatric Inventory (NPI) evaluates a wider range of psychopathology than comparable instruments (Cummings et al, 1994). It may help distinguish between different causes of dementia, records severity and frequency separately, and takes 10 minutes to administer. The NPI assesses ten domains: delusions; hallucinations; dysphoria; anxiety; agitation/aggression; euphoria; disinhibition; irritability/lability; apathy; and aberrant motor behaviour. A screening strategy is used to cut down the length of time the instrument takes to administer, but obviously it takes longer if replies are positive. It is scored from 1 to 144 and severity and frequency are independently assessed. The NPI has been translated into many languages and it is now used widely in drug trials.
The BEHAVE-AD (Reisberg et al, 1987) takes 20 minutes to administer by a clinician and was designed particularly to be useful in prospective studies of behavioural symptoms and in pharmacological trials to document behavioural symptoms in patients with Alzheimer's disease. The BEHAVE-AD is the original behaviour rating scale in Alzheimer's disease. It is in two parts: the first part concentrates on symptomatology, and the second requires a global rating of the symptoms, on a four-point scale of severity. The domains covered are paranoid and delusional ideation; hallucinations; activity disturbances; aggression; diurnal variation; mood; and anxieties and phobias.
Cornell Scale for Depression in Dementia:
The Cornell Scale (Alexopoulos et al, 1988) is specifically for the assessment of depression in dementia and is administered by a clinician. It takes 20 minutes with the carer and 10 minutes with the patient. It differs from other depression scales in the method of administration rather than in analysis of any different symptom profile seen in depression with dementia compared with depression alone (Purandare et al, 2001). The 19-item scale is rated on a three-point score of 'absent', 'mild or intermittent' and 'severe' symptoms, with a note when the score is unevaluable. A score of 8 or more suggests significant depressive symptoms. It is the best scale available to assess mood in the presence of cognitive impairment.
| Activities of Daily Living:|| |
Bristol Activities of Daily Living Scale was designed specifically for use in patients with dementia (Bucks et al, 1996). The scale assesses 20 daily living abilities.
There are 2 scales available and standardised in India for functional assessment of the elder patient. The Everyday Abilities Scale for India (EASI) (Fillenbaum et al, 1999) is a 12-item scale that can be easily scored after the history is gathered from the family. It has both components of functionality in basic Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). The Instrumental Activities of Daily Living Scale for Elderly (IADL-E) (Mathuranath, 2005) was developed by using 11 IADL items that are commonly carried out by Indian elders. The Scale is able to give a composite index of cognitive and physical disability.
| Depression Rating Scales|| |
- Center for Epidemiologic Studies Depression Scale (CES-D). The scale consists of ratings of 20 behaviors and feelings, and the patient indicates how frequently each was experienced over the past week (from no days to most days).
- The Geriatric Depression Scale (GDS) was developed because the scales discussed earlier present problems for older persons who have difficulty in selecting one of four forced-response items. The 30-item GDS permits patients to rate items as either present or absent; it includes questions about symptoms such as cognitive complaints, self-image, and losses. Items selected were thought to have relevance to late-life depression.
- Hamilton Rating Scale for Depression (Ham-D) is by far the most commonly used clinician rated scale. The advantage of having ratings based on clinical judgment has made the Ham-D a popular instrument for rating outcome in clinical trials.
- Montgomery-Šsberg Rating Scale for Depression. This scale follows the pattern of the Ham-D and concentrates on 10 symptoms of depression; the clinician rates each symptom on a scale of 0–6 (for a range of scores between 0 and 60).
| Other Measures of Psychiatric Symptomatology|| |
Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale (BPRS) takes about 20 minutes and is administered by a trained interviewer. The BPRS is a 16-item, seven-point ordered category rating scale, which has been developed through previous versions (Overall & Gorham, 1962). The questions are completed in 2-3 minutes following the interview.
Cambridge Mental Disorders of the Elderly Examination & Geriatric Mental State examination
The Cambridge Mental Disorders of the Elderly Examination (CAMDEX) and the Geriatric Mental State Examination (GMS) are semi structured instruments which are designed to do a standardised psychiatric interview for the elderly. The resulting information provides a formal diagnosis in many diagnostic categories (eg. dementia, delirium, depression, mania, paranoid disorder, schizophrenia, anxiety and other neurotic disorders etc).
| Geriatric Psychiatric Diagnosis|| |
The commonly accepted diagnostic categories would be the DSM IV-TR or the ICD 10. The new classificatory system of the DSM-5 is quite different as it lays emphasis on a categorical/dimensional model. The organic disorders have undergone major revisions and have been designated as the Neurocognitive disorders.
However most elderly are not known to fit into the diagnostic categories as they have multiple overlap of symptoms. Hence geriatricians have suggested a syndromal approach. The syndromal diagnosis enables a therapeutic approach and emphasises the multiple presentations and co morbid medical illnesses in the Elderly. Blazer (2003) has identified 7 Syndromes as below:
- Acute Confusion or Delirium is a transient organic brain syndrome characterized by acute onset and global impairment of cognitive function. In elderly at times a Hypoactive delirium is seen with apathy. There are biological, cognitive and environmental contributors
- Memory Loss or the Dementia syndrome that is a frequent but disabling syndrome. It has a sustained decline in cognitive function with insidious onset
- Insomnia is more frequent than in any age group. They may be Primary or Secondary. Others are Sleep Apnoea and Nocturnal Myoclonus
- Anxiety which may be Primary as GAD, Panic disorder; or Secondary to Organic disorders or co morbid with other Psychiatric disorders
- Suspiciousness specially when experiencing cognitive impairment ranging from distrust, increased cautiousness to paranoid delusions
- Depression that is most disabling subjectively and can be grief, depressed mood co morbid with dementia, major depression or late life depression. Cognitive impairment and psychotic symptoms may be present and a challenge in treatment.
- Hypochondriasis is a common and frustrating somatoform syndrome. Some organic finding may be present but not explain the symptoms and the symptoms do reach delusional proportions
In making a diagnosis in geriatric psychiatry it is useful to follow an algorithmic approach and use a decision tree for the better diagnosis and plan of management as is shown below.
*At all levels organic component and addictive substances should be kept in mind as a possible contributory factor. Also, disorders mentioned at higher level can have symptoms mentioned further below.
| Conclusions|| |
Accumulated evidence indicates with moderate-to-high confidence that comprehensive geropsychiatric assessment is effective when coupled with ongoing implementation of the resulting care plan. The most consistently demonstrated favourable outcomes of comprehensive geropsychiatric assessment have been prolonged survival, reduced annual medical care costs, and reduced use of acute hospitals and nursing homes. Although the evidence allows for alternative interpretation, it is probable that careful selection of patients has contributed importantly to the ability to demonstrate benefit from comprehensive geropsychiatric assessments. In view of the seemingly indispensable role of monitoring and implementation of the care plan in achieving desired outcomes, ongoing health care should be linked systematically to the process of comprehensive geropsychiatric assessment.
Thus, comprehensive assessment is an important pre-requisite for planning psychiatric and medical care of this vulnerable population group. This will help in better diagnosis, holistic management of the patients' health problems as well as building the doctor patient relationship and work satisfaction for the doctors.
| References|| |
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC, American Psychiatric Association, 2013
Blazer DG: Geriatric Psychiatry. Textbook of Clinical Psychiatry. Ed. Robert Hales, Stuart Yudofsky Fourth Edition 2003
Burns, A. Lawlor, B. and Craig, S. Rating scales in old age psychiatry. Br. J. Psychiatry, Feb 2002; 180:161-167
Devanand, DP. Psychiatric Assessment of the older patient. Comprehensive textbook of Psychiatry. Ninth Edition Ed Benjamin Sadock and Virginia Sadock 2009
Gallo, JJ, Fulmer, T, Paveza, GJ, and Reichel, W. Handbook of Geriatric Assessment, 3rd edition. Gaithersburg, MD: Aspen Publishers; 2000: pp 101-148.
Mugdha E. Thakur, Dan G. Blazer, David C. Steffens (Eds). Clinical Manual of Geriatric Psychiatry, American Psychiatric Association, 2014
Pinto C. “The Geropsychiatric Interview: Assessment and Diagnosis”. In: Clinical Practice Guidelines for Geriatric Psychiatry, Indian Psychiatric Society, 2007
Geriatric Psychiatry Services, NIMHANS, Bangalore, Professor of Psychiatry, National Institute of Mental Health & Neuro Sciences (NIMHANS), BANGALORE-560029
Source of Support: None, Conflict of Interest: None
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